DIRECTOR'S COLUMN

COVERAGE CHANGES AND THE SAFETY NET

Who will remain uninsured, and who will gain coverage in the next few years? The characteristics of both groups have implications for Minnesota’s rural and urban health care safety net.

Two recent reports estimate coverage and uninsurance in Minnesota as health reform changes roll out. A study for the Minnesota Department of Commerce estimates that the number of uninsured in Minnesota will drop by 290,000, leaving 210,000 uninsured ("The Impact of the ACA and Exchange on Minnesota," Minnesota Department of Commerce, April 2012). An analysis by the Urban Institute estimated that 230,000 would have remained uninsured if the Affordable Care Act had been in place in 2011 ("Who Will Be Uninsured After Health Insurance Reform?" Urban Institute, March 2011) .

Over half of the newly covered - about 165,000 people - will have incomes below 200 percent of the federal poverty level (FPL), according to the Commerce Department report. Two of the groups that will grow are those publicly insured and those securing private policies through the developing health insurance exchange, which expects enrollment from employees in small firms and those in the individual market. Public programs will also expand by over 100,000 enrollees. Of the newly insured, 29 percent will be non-white or Hispanic.

Source: Minnesota Department of Commerce, "The Impact of the ACA and Exchange on Minnesota," April 2012.

Who will remain uninsured? About half, or 105,000 to 111,000, will have incomes under 138 percent of poverty. Most of these will be eligible but not enrolled in public programs or the exchange, and a share will be young and single. Over one third (36 percent) will be exempt from the mandate, some because they do not have an affordable insurance option. Another third (34 percent) will be non-white or Hispanic, 12 percent will be undocumented immigrants and 43 percent will be subject to the mandate but not insured.

In addition, many Minnesotans of course will continue to be covered by Medicare. In rural areas, the already high proportion of the population covered by Medicare will continue to grow.

What are the implications of these changes for Minnesota’s safety net of rural health providers and inner-city community clinics?

In rural areas, where many are employed part time, by small business or self employed, many of those now insured will likely receive better coverage through the plans and subsidies available in the health insurance exchange. Others in these groups will be able to buy insurance for the first time. All can be expected to seek care more regularly. In addition, undocumented immigrants will continue to be uninsured and some who are marginally employed may still lack affordable options.

Overall, demand for services in rural Minnesota will rise from the newly covered and the growing Medicare population, and the uninsured will be a smaller but still noticeable component of the community. More will likely seek mental health services, exacerbating the demand on already thin mental health resources and bringing even more mental health conditions into primary care offices. The demand for dental services will also rise as more people gain public coverage.

In the Twin Cities, a significant portion of the newly insured will be the current clientele of Federally Qualified Health Centers and other community clinics. Many of these patients will now arrive with a payment source. In addition to more insured and public programs patients, undocumented immigrants and other uninsured will remain. As the Urban Institute put it, “Safety net providers and programs will still face the challenge of substantial numbers of uninsured who cannot afford a full range of needed services.”

One place to look for an example of health reform’s effect on community health centers (CHCs) is Massachusetts. Massachusetts’ CHCs, which treated many uninsured patients before that state’s 2006 reform law, expected to lose them when they became insured. Instead, health centers gained 100,000 patients, a 31 percent increase in volume, though costs rose slightly more than revenues from these patients. Massachusetts patients report that they go to CHCs because they are convenient, affordable and provide additional services. ("Safety Net Providers After Health Reform: Lessons from Massachusetts," Leighton Ku et al. Archives of Internal Medicine 171[15]: 1379-84, Aug. 8, 2011).

For all these rural and urban safety net providers, demand for both more primary care providers, specialists and staff at all levels will grow. Facilities may need to be expanded. Health information technology systems must be in place, hours will need to be extended and more.

How can providers and policymakers prepare for these changes? In addition to continuing efforts to grow the health care workforce, resources will need to be stretched through team-based care to meet new demand and the expectations for coordination and outcomes under reform. There will also be opportunities for health promotion and prevention. In rural Minnesota, the case for Federally Qualified Health Centers in communities like Bemidji, Princeton and Tower will be even stronger, and opportunities to establish FQHCs in southwest Minnesota and other areas should also be explored.

This is also the time to make tangible the contribution telehealth can make, especially in mental health. And there will clearly be a role for safety net providers in connecting patients to options available in the health insurance exchange, and perhaps an ongoing role for community coverage approaches such as those developed by Portico in the Twin Cities and PrimeWest in rural Minnesota. State and federal financial support for safety net providers will remain important.

As always, the Office of Rural Health and Primary Care is here to provide support in these changing times. Please let us know how we can help as you plan for reform.

Mark Schoenbaum is director of the Office of Rural Health and Primary Care and can be reached at mark.schoenbaum@state.mn.us or 651-201-3859.

PARTNER FOCUS

The case for integrating primary and mental health care services seems to grow stronger every day. More primary care providers are seeing patients with untreated mental health problems. Many individuals with mental health disorders go without needed medical care. Failure to treat co-occurring physical and mental health conditions – especially common among those with chronic conditions such as diabetes, asthma and heart disease – leads to poorer health outcomes and higher costs.

Even so, true integration of care remains rare and difficult.

The experience of Community-University Health Care Center (CUHCC) in south Minneapolis, long a leader in community-based mental health and primary care, shows both the promise and the challenge of fully integrating such services. As a Federally Qualified Health Center, CUHCC is unique in Minnesota in the range of mental health services offered – including therapy, psychiatry, case management for adults with serious and persistent mental illness (SPMI), and adult rehabilitative mental health services (ARMHS). It is also unusual in the number of patients receiving services in multiple, often integrated areas of care: Of 1,661 behavioral health patients, 67 percent also receive medical services at CUHCC and 31 percent receive mental health, medical and dental services.

A gradual progression toward integration

The health center’s approach to integration reflects its history and a gradual evolution. First established as a pediatric clinic in 1966, CUHCC offered a full-fledged mental health program and dental services before it added adult medical care in 1975. A first step in integrating those services was to create an overall Clinical Director, who oversees most of CUHCC’s clinical services (across medical, behavioral and dental). With the support of a Healthier Minnesota Community Clinic Fund grant, it then added medical assistant staff dedicated to supporting behavioral health patients. Today, over 90 percent of those patients are now screened regularly for blood pressure, weight and tobacco use, with medical care follow up as necessary, supported by an Electronic Health Record (EHR) for each patient shared by all their providers.

Care for patients initially seen on the medical side but identified as having mental health needs is not as immediately integrated – that is, same-day dual care is not generally possible, in part because of the diagnostic assessment required to establish medical necessity for mental health services. However, such patients are flagged in the shared Electronic Health Record (EHR) system and nurses work to coordinate their follow-up care. Medical and mental health providers often consult on such cases as well. Integration with dental care is still more difficult, but the shared EHR helps here too, and occurs increasingly with CUHCC’s pediatric patients in particular.

CUHCC’s next phase is to develop integrated care teams around major patient populations, including teams for women’s health, pediatric preventive care, adult preventive care, OB services, diabetes and depression. Their hope is to have “care managers” who can work with a panel of 60-70 patients each and serve as a bridge across the various providers and services needed by a given patient.

The challenge of different training, different funding

Attaining integration hasn’t been easy for CUHCC, nor is it complete. “Integration is really a work in progress,” says Colleen McDonald Diouf, CUHCC’s Associate Director. “You don’t just achieve it, especially since medical and mental health training and funding sources continue to be so different from each other. It’s an ongoing journey across those differences.”

And those differences are significant. Primary care and behavioral health providers come to patient care with dramatically dissimilar cultures, languages and processes. This has been the toughest part of integration, according to McDonald Diouf. “Bringing the two disciplines' perspectives together, so one doesn’t feel dominated by the other, is an ongoing issue,” she says.

A second major challenge is financial. As a Rule 29 provider through the Department of Human Services, CUHCC is reimbursed for mental health services provided under that program. A mental health provider must first complete a full diagnostic assessment, however, a process that can take 1-2 visits. This complicates and slows integration with medical care.

Other challenges have included the physical layout of the clinic – how to provide an environment that supports the distinct needs of medical services and behavioral health care, but also integrates those services – and finding support staff, such as the medical assistants who have played such a crucial integrative role at CUHCC, who understand how the two disciplines work and are willing to work with a patient population experiencing serious mental illness.

Words of wisdom

Despite these challenges, CUHCC has found integration to be a powerful and worthwhile strategy, and one it continues to pursue. McDonald Diouf offers these lessons learned for other organizations looking to integrate their services:

Most importantly, build teams. When providers are able to work across disciplines to serve a complex patient, they feel a tremendous amount of satisfaction in the quality of care they are able to provide.

Be aware of -- and work through -- differences in how the disciplines are trained and their clinical approaches.

Make provider roles clear, particularly around diagnosis issues, work flow and approach.

Be ready to work through differences in how medical and mental health services can be billed.

Enlist clinical champions on both sides.

Know it will take a lot of time and dedicated resources to make it happen.

Use “bridge” positions such as care managers, nurses and others to help integrate services, but know they must build trust with all disciplines for integration to be effective.

SPECIAL FEATURE

RURAL HOSPITAL CEOs TALK HEALTH REFORM AND MORE

This year’s Minnesota Rural Health Conference, held in Duluth in late June, included a roundtable discussion among the Chief Executive Officers of three rural hospitals. The following are some of the major themes that emerged there and echoed throughout the conference.

Major change is coming – and in key ways rural Minnesota is well positioned for it. This year’s conference resonated with questions and predictions about how health reform will play out in rural settings. The three CEOs agreed it will cause significant shifts, but also spoke to ways their hospitals have already begun making changes that position them well for reform -- including quality initiatives such as the RARE campaign (Reducing Avoidable Readmissions Effectively), which appears to be successfully improving a measure that will affect hospitals’ reimbursement from Medicare. Others have begun integrating services and exploring relationships with other systems and public health – what Riverwood Healthcare Center CEO Michael Hagen called “value contracting.” Riverwood, located in Aitkin, has also changed how it pays providers, now basing it partly on risk and quality rather than simply productivity.

Other conference presentations also highlighted ways rural Minnesota may be well suited to the impending change. Many rural areas are already very focused on primary care as the foundation of the local health system, and integrate those services with both the community and the hospital. They also have strong histories of partnering to provide services. In the conference’s policy forum, Commissioner of Human Services Lucinda E. Jesson noted this positions them well for collaboration on key issues like readmissions and care transitions.

Many hospitals in rural Minnesota also appear to be on a strong financial footing for reform, at least for now. A presentation at the roundtable of hospital CFOs showed that as of 2010, most Critical Access Hospitals (CAHs) in Minnesota were at low risk for financial distress and none were at high risk. Most were also performing well in key financial benchmarks, including cash flow margins.

Still, challenges lurk. The CEOs touched on two of the biggest issues about health reform raised at the conference: access and new payment methodologies. The opening keynote called access the most important issue of all. “My fear is that in building a more efficient system, we’ll lose access, especially for rural populations,” said Bill Finerfrock, Vice President of Health Policy at Capitol Associates in Washington DC. “We need to make sure this is re-inserted into the policy discussion.” The CEOs at the roundtable agreed it will be key, particularly across the various levels of care.

Riverwood CEO Michael Hagen of Aitkin called the prospect of bundled payments a “looming issue” and potentially a big problem for CAHs. As a CAH, his hospital is now reimbursed for its costs under Medicare, but faces financial challenges serving other patients. At the policy forum later in the conference, Stratis Health CEO Jennifer Lundblad went further, saying that rural health advocates are “kidding ourselves if we think the CAH cost-plus reimbursement system can be sustained.” Or as Lawrence Massa, president of the Minnesota Hospital Association, put it: “Rural people can be leaders on the delivery side, but I worry about the financial side.”

Either way, the new era will require more partnerships and different structures. The CEOs agreed the future will require even higher degrees of collaboration and different ways of delivering services. This echoed the conference’s keynote speech, in which Bill Finerfrock predicted that hospitals will no longer be able to operate as “islands,” but instead will need to integrate and coordinate with other providers, particularly with primary care as the portal into larger systems.

This won’t necessarily take the form of Accountable Care Organizations (ACOs), however, which Finerfrock doesn’t believe will work in rural settings. None of the three CEOs at the roundtable see themselves playing a leading role in ACO, either. River’s Edge Hospital and Clinic in St. Peter is exploring a virtual ACO with other independents, said CEO Colleen Spike, though even then rural communities' small size may be an issue.

Focusing on community need will be key. Numerous conference participants, including these CEOs, emphasized basing decisions above all on a given community’s unique characteristics. “Today there is more talk about growth to fully meet community need,” said Spike of River’s Edge. This local focus can also help decisionmakers navigate and evaluate the many options emerging, according to Stratis’ Lundblad: “Stay focused on what your community needs rather than latching on to all the new ideas or chasing models designed for urban areas.” It may also help with difficult decisions about which service lines a hospital may need to drop or provide indirectly. “It gets to the heart of the community,” said David Nelson, of St. Francis Healthcare Campus in Breckinridge, but is increasingly necessary.

RHAC MEMBER PROFILE

Please explain your professional work to us . . .

I’m a family physician and I’ve practiced family medicine in Moose Lake for 40 years. I’m also currently assistant dean for rural health for the University of Minnesota. I also serve as Medical Director for Mercy Hospital and Augustana Mercy Health Care Center in Moose Lake, and I’m treasurer of the Minnesota Academy of Family Physicians.

At the national level, I am currently involved with the National Rural Health Association (NRHA). I’m on the NRHA Board and chair the Clinical Services Constituency Group, which I’ve done for some time. I also serve on its Government Affairs Committee and the Rural Congress, the policymaking body of the NRHA. I’m also a Minnesota Medical Association delegate to the American Medical Association (AMA).

And your life away from work?

There isn’t any! No, away from work I enjoy family and walking. I live on the North Shore and walk every day on Old 61. I also really enjoy the night sky – the Northern Lights, the planets and stars. I’m also involved in the Masons and currently serve on the Minnesota Masonic Charities Board, which grants scholarships and supports other important causes.

What do you think are the most important issues facing rural health?

My mission is to provide access to high-quality health care to rural citizens and their visitors, and I try to make my decisions based on that. Right now, the big issue is how to maintain access and how that might be affected by the Affordable Care Act.

I think it’s important that we try to bring the strength and resiliency of rural communities to health care policy. I think all of health care policy would benefit from looking more closely at what we do in rural, particularly how we bring community into health care.

Finally, the struggle for a health care workforce continues. My work at the university is to make sure we train rural family physicians, including physicians for Native American communities. One of the most difficult problems right now is finding rural training sites and preceptors for medical students. We need preceptors in rural communities.

What do you think would make the most difference for rural health?

The thing that’s going to make the most difference for health care – health care period, not just rural health care – is the large untapped resource we have in the patient. That is, the patient taking responsibility for their own health and health care. It has to do with prevention and it has to do with all the related pieces – including that I as a physician explain and teach in a way that’s assisting patients with their care and not preaching. We need our rural citizens to take ownership of their health. If we could make that happen, it could save a lot of money. Some say that’s the largest untapped resource we have available right now for better health care and better health care outcomes.

I also hope we can continue finding rural young people who are willing to go back and serve their community in the health care workforce. In my case, it’s finding doctors, but it’s not only physicians we need.

The Rural Health Advisory Committee advises the commissioner of the Minnesota Department of Health and other state agencies on rural issues; provides a systematic and cohesive approach toward rural health issues; and encourages cooperation among rural communities and providers. Meeting information is online.

MISSION: To promote access to quality health care for rural and underserved urban Minnesotans. From our unique position within state government, we work as partners with communities, providers, policymakers and other organizations. Together, we develop innovative approaches and tailor our tools and resources to the diverse populations we serve